- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $12.59 / $12.59
| Facility | 26 | $12.59 | $12.59 | $12.59 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $95.50 / $102.33
| Facility | TC | $34.67 | $95.50 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $34.67 / $72.44
| Professional | | $21.38 | $34.67 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.08 / $10.00 / $21.38
| Professional | 26 | $7.08 | $10.00 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $25.12 / $50.12
| Professional | TC | $15.85 | $25.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $43.65 / $63.10
| Professional | | $30.20 | $43.65 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.32 / $12.02 / $17.38
| Professional | 26 | $8.32 | $12.02 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $30.20 / $45.71
| Professional | TC | $22.39 | $30.20 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $42.66 / $81.28
| Professional | | $31.62 | $42.66 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.23 / $13.18 / $25.70
| Professional | 26 | $10.23 | $13.18 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.42 / $30.20 / $58.88
| Professional | TC | $20.42 | $30.20 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $52.48 / $95.50
| Professional | | $38.90 | $52.48 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $13.80 / $25.70
| Professional | 26 | $10.96 | $13.80 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $37.15 / $70.79
| Professional | TC | $30.20 | $37.15 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | 26 | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | TC | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $38.90 / $75.86
| Professional | | $27.54 | $38.90 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.94 / $11.48 / $21.38
| Professional | 26 | $7.94 | $11.48 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $28.18 / $54.95
| Professional | TC | $19.05 | $28.18 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $47.86 / $95.50
| Professional | | $32.36 | $47.86 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.33 / $13.80 / $54.95
| Professional | 26 | $9.33 | $13.80 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $30.90 / $54.95
| Professional | TC | $22.39 | $30.90 | $54.95 |